Application

Information Name: ___________________ Address: ___________________ Home Telephone: ___________________ Work Telephone: ___________________ E-Mail Address: ___________________ Date of Birth: ___________________ Age at 1st Marathon: ___________________ Number of Marathons: ___________________ Number of Ultra's: ___________________ Total Marathons and Ultra's: ___________________     Jerry Schaver 1124 16th Street Ct. Silvis, Illinois 61282

Date:___________________ Please List 10 Marathons Run (Date/Finish/Time/State) 1. ___________________ 2. ___________________ 3. ___________________ 4. ___________________ 5. ___________________ 6. ___________________ 7. ___________________ 8. ___________________ 9. ___________________ 10. ___________________ (Attach Favorite Photo) + $10 Membership Fee Printer Friendly Version   Please make checks payable to: Jerry Schaver